A novel surgical technique to prevent post-enucleation conjunctival cyst: conjunctival staining with methylthioninium

Dear Editor,

Conjunctival cyst of the orbit acquired from enucleation is an infrequent but serious complicationwhich can occur in 3%-7% of patients, more commonly after a secondary procedure. The most common manifestations are the inability to retain the external prosthesis, foreign body sensation or bleeding. Treatment by excision, marsupialization, or injection of sclerosing agents (absolute alcohol, trichloroacetic acid, and sodium tetradecyl sulfate)have been proposed.However, recurrent conjunctival incisions may lead to barrier weakness and implant exposure, scarring, and shortening of the conjunctival surface area. Despite the variety of treatments,the cosmetic result can be poor. For example, implant removal or replacement was required in 8 of 9 cases presented by McCarthyand 3 of 5 cases by Smit.

我们或许可以把“握手”解释成接触，接触即意味着建构。人生而被建构，烙印即被建构的标记，来自于无形；“我”又将其施于他人，人为自己建构，为自身寻找存在的意义。每一次建构，无论源于无形，亦或施于有形，无论是无意识的，还是有意识的、自觉的，皆是一次重构，烙上一标记。

The mechanism of conjunctival cyst in an anophthalmic orbit is postulated as follows: 1) the inadvertent implantation of a free fragment of conjunctival tissue within Tenon’s capsule during enucleation surgery; 2) incarceration of a tongue of conjunctiva that is accidentally inverted in wound closure through Tenon’s capsule; 3) epithelial down-growth. To prevent an acquired conjunctival cyst, it is therefore important to close Tenon’s capsule and conjunctiva with great care as two separate tissues. In fact, however, the conjunctiva may be difficult to distinguish from Tenon’s capsule due to surgery-induced tissue swelling and collapsed orbital tissue in secondary implantations. We report herein the use of conjunctival methylthioninium stain to aid visibility of and distinction between the conjunctiva and Tenon’s capsule.Written informed consent was obtained by the patient to allow publication of the present case and any related image and this case study is in accordance with the tenets of the Declaration of Helsinki.

推进国家治理体系和治理能力现代化，是党全面深化改革的目标，也是党在新时期实现政治改革的重要内容。在向社会主义现代化迈进的过程中，国家治理是党探索政治改革道路的重要举措。思想政治工作作为党的传统政治优势，在传播党的政治价值和政治理念方面发挥着不可替代的作用，但是适应现代化发展的需要，它也面临转型的课题。在现代国家治理体系中，思想政治工作的功能定位直接决定了其结构转型的方向。

A 45-year-old male, otherwise healthy, with an enophthalmic right eye was referred to our hospital at the patient’s request,for cosmetic enhancement. The patient had a history of penetrating trauma and emergent surgical repair to his right eye, one year previously. The vision of the right eye was no light perception and B-scan ultrasound revealed atrophy of the right eye. No abnormality was observed in the left eye.After informed consent was obtained, evisceration surgery was performed under general anesthesia.

In conclusion, the topical application of methylthioninium is a simple, inexpensive, non-invasive approach which can be used for better visualization of the conjunctiva during enucleation and orbital implant surgery, both primary and secondary, so that complete distinction between the conjunctiva and Tenon’s capsule can be achieved and conjunctival cyst may be avoided.Secondary conjunctival inclusion cysts have also been reported after other ocular surgeries, including strabismus surgery,ptosis repair, phacoemulsification with pars plana vitrectomy,and penetrating orbital injury surgeryand this procedure may potentially be used in these surgeries.

After routine sterilization of the area undergoing surgery, a dry cotton-swap was used to remove superfluous fluid in the conjunctival sac, to avoid unnecessary spread of methylthioninium and to facilitate visibility of the area of interest. A second dry cotton-swap was soaked with 10 mg/mL methylthioninium(JUMPCAN Pharmaceutical Group Co.LTD, China), and conjunctival staining was accomplished by rolling this cottonswap on the conjunctival surface (Figure 1A). A standard procedure evisceration and orbital implant placement was then undertaken. Finally, prior to wound closure, the conjunctiva was separated from Tenon’s capsule, facilitated by selective staining of the conjunctiva (Figure 1B). Tenon’s capsule(Figure 1C) was sutured using 6-0 absorbable Vicryl (Johnson& Johnson, New Brunswick, New Jersey, USA) followed by conjunctival suture (Figure 1D) using 8-0 absorbable Vicryl(Johnson & Johnson, New Brunswick, New Jersey, USA).

Methylthioninium, as a common mucosal stain, is widely used in gastric endoscopy examinations. In the eye region,it is mainly used for external procedures, such as excision of pterygium. In this report, we used methylthioninium for better visualization of the conjunctiva, particularly at the incision site, which was otherwise not easily distinguished from Tenon’s capsule due to tissue swelling. To our knowledge, this is the first report of a procedure of this kind.Although methylthioninium stains capsules, it can be toxic to intraocular structures in concentrations above 0.5%. The effects of accidental injection of methylthioninium into human eyes, such as sterile endophthalmitis, have been reported.However, in animal models, methylthioninium shows no major side effects on the external surface of the eye, indicating that it is relatively safe in orbital implant surgery. Other stains such as toluidine blue, trypan blue, and indocyanine green, may also be useful for this purpose. Toluidine blue is a dye with similar chemical structure and physicochemical properties to methylthioninium; however, it is approximately five times more expensive than methylthioninium and may not be available in rural ophthalmology units. Trypan blue and indocyanine green are significantly more expensive, and trypan blue is a potentially carcinogenic vital dye in animal models,limiting their application. In contrast, methylthioninium is advantageous based on its relatively high availability and safety, and low cost.

Conception and design were performed by Qian J; surgery and writing were performed by Li XF.

Supported by the National Natural Science Foundation of China (No.81970835).

4.2.1 以健康中国战略为引领，关注城乡群众体育协调发展 2016年10月25日，中共中央 国务院印发的《“健康中国2030”规划纲要》中指出：“全民健康是建设健康中国的根本目的”[20]。自2008年北京奥运会以来，尽管我国群众体育发展迅速，但城乡差别依然很大，农村群众体育基础设施落后、农民健身意识不强等都是制约我国农村群众体育发展的重要因素，而农村群众体育的发展水平对于健康中国战略的推进落实具有重要影响。因此，以健康中国战略为引领，关注我国城乡群众体育的协调发展，这将是未来很长一段时间我国群众体育研究重点探讨的课题。

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